Provider Demographics
NPI:1457514341
Name:LIDEN, MATS LARS (MD)
Entity Type:Individual
Prefix:DR
First Name:MATS
Middle Name:LARS
Last Name:LIDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1450 NW 6035
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55485-6035
Mailing Address - Country:US
Mailing Address - Phone:952-542-8553
Mailing Address - Fax:
Practice Address - Street 1:166 19TH STREET SOUTH
Practice Address - Street 2:SUITE 100
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2154
Practice Address - Country:US
Practice Address - Phone:320-251-0609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE57482085R0202X
MN551092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology